Case Management

Question 1

Pre Op Assessment Keys:

Answer 1

Co-existing Medical conditions: URI, fever etc
Birth/Prematurity/Neonatal Complications Hx
Social Hx/smoke exposure
Anesthetic Hx

Question 2

NPO Status (for healthy kids)

Answer 2

CLQ = 2 hrs // Breast milk = 4 hrs // Formula, juice, dairy milk = 6 hrs // solids = 8 hrs
Cows milk = longer digestion, curdled/solid aspirate
Breast milk = shorter digestion, liquid aspirate

Question 3

Lab Testing Indications

Answer 3

Heme - <1yr if premie, hx CA, bleeding disorder
Chem - renal, adrenal, endo, CNS disorder
LFTs - Hx liver disorder
Coag - leukemia, hepatic disorder, malnutrition, bleeding disorder

Question 4

Goals of Pre-medication

Answer 4

Decrease anxiety/fear / Produce amnesia/analgesia // Facilitate anesthetic induction // Facilitate separation from parents // Block vagal reflexes // decrease secretions // aspiration prophylaxis

Question 5

Atropine and Central antiAch syndrome

Answer 5

Central nervous system (CNS) manifestations result from central cortical and subcortical muscarinic receptor antagonism. The degree of CNS manifestation is related to the drug’s ability to cross the blood-brain barrier. Physostigmine, a lipid soluble tertiary amine anticholinesterase drug administered in doses of 15 to 60 μg/kg IV, is a specific treatment for the central anticholinergic syndrome. Treatment may need to be repeated every 1 to 2 hours.

Question 6

Signs/Symptoms of Central AntiAch syndrome

Answer 6

Red as a beet (flushing)
Dry as a bone (no secretions)
Blind as a bat (mydriasis)
Hot as a hare (anhydrosis)
Mad as a hatter (agitation, restlessness)

Question 7

Atropine Dosing/Contraindications

Answer 7

Dose IV/PO 0.02 mg/kg, min is 0.1 mg. Careful with cardiac abnormalities and risk of MH (masks tachy signs). IV dose at induction, PO dose 30-60m prior, max dose 0.6 mg

Question 8

Pre-Op Narcotics

Answer 8

Rarely used, OT with diff/variable dosing, IM diff to admin.

Overall disadvantages: vomiting, pruritis, excess sedation, hypoventilation/resp depression.

Question 9

Barbiturates - gaba-mimetic, depress RAS

Answer 9

Not utilized d/t long duration and residual sedation. Methohexital PR most likely used. PR = 20-30 mg/kg, IM 6-10 mg/kg, IV 1-2 mg/kg. Duration up to 5 hrs. Not used if <6mo d/t very limited metab and variable PR uptake.

Question 10

Bnezodiazepines - gaba-mimetic

Answer 10

Versed most widely used, most reliable, simple PO administration, PO = 0.5-0.75 mg/kg, max 20mg. May add tylenol for analgesia/amnesia/sedation combination.

Question 11

Ketamine - NMDA antagonist, dissoc anesthetic

Answer 11

Not routinely used, poss proc sedation 0.2-1mg/kg IV, pre-emptive analgesia at 0.1-0.2 mg/kg IV. PO = 3-6 mg/kg, PR 6 mg/kg onset 10-30m. IM 4-5 mg/kg

Question 12

Chloral Hydrate unknown MofA, cns depressant

Answer 12

Field trip sedation MRI/CT. 50-75 mg/kg PO/PR, variable onset 20-40m, long duration w/o reversibility, poss arrhythmias

Question 13

GI prophylaxis

Answer 13

Metocloperamide - IV 0.1 mg/kg - dopa/sero antago in CTZ, incr tissue sens to Ach to incr GI motility, incr LES tone
Cimetidine - IV 5/10-20/20-30 mg/kg/day neo/inf/child - H2 rec antago on parietal cells, inh gastric secretions
Ranitidine - 0.75-1.5 mg/kg/day children - same
Sodium Bicitra - PO 0.4 ml/kg - non particulate antacid
Most need to be given 60m pre-op

Question 14

Acetaminophen

Answer 14

Most widely used analgesic. Give prior to sx incision.

IV 30 mg/kg q6 / PO 20-30 mg/kg q8 / PR 40-60 mg/kg q8

Question 15

Dental Evaluation

Answer 15

Rule of 6-2-6-12
first deciduous tooth @ 6 mo (letter top R-->L, bottom L-->R
deciduous teeth complete @ 2 yrs
first permanent tooth @ 6 yrs (molars)
permanent teeth complete @ 12 yrs
Suspect loose teeth at 5-12 yrs

Question 16

Breathing Circuits: Mapelson

Answer 16

Most commonly used is “D” circuit
Adv: lightweight, low resistance, small Vd
Dis: heat/moist loss, no scavenging, high FGF (2-3x MVe), no CO2 absorbent
“D” –> basis for Bain Circuit
“F” –> Jackson Reese Circuit

Question 17

Breathing Circuit: Bain

Answer 17

Adv: low Vd, conserves heat, scavenging present
Dis: unable to directly inspect insp limb, FRG tube rupture –> rebrth CO2, no CO2 absorbent = high FGF

Question 18

Breathing Circuit: Circle system

Answer 18

Adv: conserves heat/humidity, use low flows, scavenging, CO2 absorbent
Dis: valve + CO2 abs == incr resistance, tubing incr Vd
Sources of Resistance: ETT, valves, CO2 absorbent

Question 19

Reservoir Bag sizing

Answer 19

NB = 0.5L / 1-3yr = 1L / 3-5yr = 2L / 5+yr = 3L

Question 20

Inhalation Induction Goals/Technique

Answer 20

Goals: Asleep fast & Ensuring progression stg 2–>3, marked by reg resp, eyes fixed/ML, extrems/abdo relaxed
Technique: FiO2 near 100% +/- N2O –> incr Sevo% quickly, stage 2 marked by excitement, irreg resp, breath holding, heighten AW reflexes (give sm amounts PPV). Should rec 100% O2 prior to intubation. Straight blade provides best lift of short/stiff epiglottis. Use OA, not NA as can damage adenoids (NP) and tonsils (OP).

Question 21

Blade Sizes

Answer 21

Mac 1 = 1-2 yrs / Mac 2 = 3-5 yrs
Mil 00 = prem / Mil 0 = neo / Mil 1 = infant-2yrs / Mil 2 = >2yr
WisHip 1 = 1-2 yrs / WisHip 1.5 = 3-4 yrs

Question 22

ETT Specifics

Answer 22

Age < 8 yrs = uncuffed ETT
Air leak @ 15-20 cmH2o
Cuff inflation pressure < 25 cmH2o
Head Extension = ETT mvmt 1-2cm --> OP
Head Flexion = ETT mvmt 1-2 cm --> lungs

Question 23

ETT Sizing Internal Diameter

Answer 23

Prem 1000gm = 3.5
Neo - 3mo = 3.0
3-9mo = 3.5 / 9-18mo = 4.0
>2yr = age/4 +4

Question 24

ETT Depth

Answer 24

** < 1yr trachea length 5-9cm, w/ = R/L bronch angles
*1kg = 6-7cm / 2kg = 8cm / 3kg = 9cm 4kg = 10cm /
4kg-1yr = 10cm / >1yr = age/2 +12
* Internal Diameter x3
* double black line of uncuffed tube passes thru vocal cord tip is proximal to carina

Question 25

LMA sizing

Answer 25

1 = neo/inf < 5kg, 4ml / 1.5 = 5-10kg, 7ml / 2 = 10-20kg, 10ml / 2.5 = 20-30kg, 14ml / 3 = > 30kg, 20ml

Question 26

Airway Assessment Keys

Answer 26

Teeth, 6-2-6-12, tongue, tonsillar hyperplasia
Mouth opening, neck ROM
Mandibular/Maxillary hypoplasia/excess
See uvula/PG arch?
Craniofacial abnormality?

Question 27

Minimizing LSpasm, Treatment

Answer 27

Extubate when fully awake or in Stage 3, mouth/eyes open spontaneously, reg respirations
Stage 2 extubation = Lspasm
Tx: 100% O2, APL @ 30-40cmH20, Repositions head + tight mask seal, ant jaw thrust, hold PPV for 10-15 secs
Give Succs @ 4-5mg/kg IV

Question 28

Dehydration Levels

Answer 28

Mild = BP, HR, cap refill WNL, 10% BW decr

Question 29

Fluid Management

Answer 29

Bolus = 10-20ml/kg over cannot handle Na load –> osmo diuresis

Question 30

PONV risk factors / treatment

Answer 30

Risk Factors: age > 3 yrs, female (post puberty), Hx of PONV, pre-op anxiety, pre-op opioids, N2O use, ENT/Lap/ear/ocular sx, forced fluids post-op
Treatment: decadron 0.15 mg/kg / zofran 0.5-0.1 mg/kg

Question 31

PASS Criteria

Answer 31

O2 sat > 92%, BP w/i 20% baseline, MAE, breathe deeply/cough, Arouasable, pain/nausea controlled
PASS score > 13

Question 32

Outpatient Pediatric Patients Criteria / Contraindications

Answer 32

OK: ASA 1-2, chronic conditions well controlled
No acute concurrent illness
Not OK: Hx prem infant < 60 wks post conceptual age up to 1 yr
BPD, apnea, req O2, SIDS Hx

Question 33

How Old is Your patient?

Answer 33

conception –> birth = gestational age
birth –> surgery time = postnatal age
conception –> surgery time = conceptual age